The Impact of Medical School Ranking on Attrition

Our data demonstrate that medical school alumni graduating from schools rated in the top 10 by US News and World Report did not have significantly different attrition from alumni of non–top 10 schools. One limitation of this analysis is that only a single measure of medical school rank was used for this study.

The Impact of Public Versus Private Versus International Medical School Training on Attrition

Despite the fact that there are a greater total number of medical students enrolled at public medical schools versus private medical schools, our data demonstrate that more physicians matched into neurosurgery graduate from private schools (n = 680) than public schools (n = 618). P ublic m edical s chool a lumni h ave significantly lower attrition than private school alumni. Four potential hypotheses are among many that could contribute to this phenomenon: 1) Private school graduates may simply be more willing to change their career trajectory than those coming from public schools. 2) It may be more difficult for public school alumni to match into neurosurgery; those who do match may be thus less likely to leave. 3) Private school alumni may have greater socioeconomic resources than public school alumni and thus may be more willing to look at other career options after matching into neurosurgery. 4) Public schools may provide better preparation for residency.

The Number of Women Entering Neurosurgery Has Increased but Is Not Commensurate With the Pipeline

In 1986, 11,551 women applied to medical school (35% of the total number of applicants); 5520 enrolled (34%) and 4957 graduated (31% of total).⁴ Eleven women matched into neurosurgery residency in 1990 (8.6% of 128; Table 1), and 9 became board certified (7.9%).

Nearly 10 years later, in 1995, 19,776 women applied to medical school (43% of the total number of total applicants); 6941 enrolled (43%) and 6501 graduated (41% of total).⁴ Seventeen of those women matched into neurosurgery in 1999 (12.7% of total; Table 1), and 9 became board certified by November 2013 (9.1%). Thus the odds of a female medical school applicant becoming a board-certified neurosurgeon fell from 1:1283 in 1986 to 1:2197 in 1995.

Between 1990 and 1999, 21 of 92 neurosurgery residency programs matched no female applicants. More than one-third of neurosurgery residency programs (33 of 92) did not have a single female matched applicant who had become board certified by November 2013 (Table 4).

Since 2004, at least 47% of medical school graduates are women.⁴ As the percentage of women graduating from medical school approaches parity with men,⁴ there has been a commensurate increase in women in general surgery, with women making up 30% of the general surgery resident positions⁸ in 2007 and 37.4% in 2011.¹ Neurosurgery and orthopedic surgery have not kept pace with the pipeline increases in female medical school graduates.⁷ In 2011, 13.6% of orthopedic surgery residents were female.¹ As per the ABNS, during the 2011–2012 academic year, 15.5% of neurosurgery residents were female.¹⁵

Women Have Substantially Higher Attrition During and After Neurosurgery Residency Training

Our data demonstrate that nearly 4 in 10 women who began neurosurgical residency between 1990 and 1999 did not become board certified, and that women were twice as likely as men not to become board certified (Table 1, Fig. 1).

Few studies have evaluated the reasons for female attrition in neurosurgery;^5,22 however, the subject has been investigated among general surgeons. Reasons for leaving general surgery residency have been evaluated in single studies on program attrition predating the 80-hour work week and found that women were more likely to leave for lifestyle reasons.^6,10 A survey of 4402 general surgery residents demonstrated that married parents reported both greater satisfaction and work-life conflict and female residents looked forward to work less than male residents did.¹⁹ Female surgeons are noted to have greater work-home conflicts than male surgeons.¹¹

Surveys of collegiality and socialization between residents and attending physicians have demonstrated that residents who are male, parents, and older are more likely to socialize with attending physicians.¹⁸ Female residents are less likely to feel that they can approach faculty when having difficulty, and residents who were unable to approach faculty were 5-fold more dissatisfied with their training.¹⁸ The fear of impropriety may impede mentoring relationships and collegiality between female residents and predominantly male faculty and peers.

Interaction with colleagues and cooperative working relationships have been found to be statistically significantly associated with job satisfaction in a survey of practicing academic physicians.¹³ Structured mentoring also improves faculty retention.²¹

Surveys of women in academic medicine have found that minority women are most likely to leave,² and the three most commonly associated reasons are inequity in professional advancement, lower salary than peers, and problems with departmental chairs and leadership.⁹ Women in academic medicine, and minority women in particular, start with lower pay and fewer research resources.^2,24 Female general surgeons are promoted less rapidly and face both overt and covert discrimination.²⁴

There are very few women in leadership roles in neurosurgery. A review of 2010 data maintained by the AANS suggested that there were 5 female tenured full professors in the US of 213 full neurosurgery professors (2.3%), excluding 39 service chiefs and 65 department chairs with unknown academic rank (AAMC data, obtained through institutional connection). There is currently one female department chair in neurosurgery. Although neurosurgery has a higher percentage of female practitioners (approximately 6%) than orthopedic surgery (4.8%), the number of female faculty members and full professors is lower. In 2012, 15% of orthopedic surgery faculty were women, with 7% serving as full professors.³

One might speculate that the relative parity of women in college and medical school and availability of female faculty mentors in other fields creates a particularly jarring experience for women who are entering neurosurgery and are abruptly facing a relative paucity of female peers, mentors, and role models. Such a phenomenon is exacerbated the higher a woman rises in the field as more and more women drop out, and she is left with no female colleagues or mentors.

General Limitations of the Data and Their Applicability

The data collected represent only those individuals who entered neurosurgery through the match and thus exclude physicians who acquired positions postmatch or obtained them through attrition of other physicians or program openings and expansions.

We assume that individuals who have practiced neurosurgery after residency as confirmed by the American Medical Association DoctorFinder and NPI have completed residency and are still practicing neurosurgery. The search algorithm in Fig. 1 suggests that once an individual is either found to be practicing neurosurgery or has completed residency, he or she is still practicing. This is not necessarily a valid assumption. Thus, it is possible that our study overestimates the number of neurosurgeons who have completed residency and/or are still practicing neurosurgery.

The accuracy of our study is limited to its recordable outcome measures. Board certification does not mean that someone is practicing neurosurgery, nor does lack of it mean that they are not. This is a limitation of the methodology that could be overcome by contacting individual programs and residents for a more rigorous study.

Due to the length of neurosurgical training, which we found to be longer than 12 years from match to board certification, the findings of this study are not necessarily applicable to individuals presently matching in neurosurgery. Residents who entered neurosurgical residency during the first 7 years of the study period completed their residencies prior to the introduction of the 80-hour work week. Those who entered residency during the last 3 years of the study period were senior enough in their training that they were not necessarily impacted by the 80-hour work week. Current neurosurgical residents have work-hour limitations that substantially alter workload, the nature of training, lifestyle, and other issues that impact attrition. Data regarding attrition linked to particular medical schools and residency training programs are particularly likely to have changed since most programs have changed leadership and faculty.

This study demonstrates that 19% of men and 37% of women who matched into neurosurgery over one decade did not become board-certified neurosurgeons, but it does not assess causality for attrition. Data regarding the specifics as to why these individuals did not become board certified and at what point in their training they came off track would enable better understanding of the discrepant attrition described in this study.